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Tc, + TO: O*E OF REVENUE AND RECOVERY <br /> TRANSMITTAL O �� <br /> ACCOUNT NO. DEPT.NO. REFERRAL 0 <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> CUSTOM METAL FINISHING <br /> C/O NAME GUARANTOR SSN <br /> NEIL DAVIS&TERRI TAYLOR <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 1550 SHAW RD #CSTOCKTON CA 95215 209-505-0037 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 4212 ELDENBERRY CT MODESTO CA 95356 209-918-0815 <br /> USER REFERENCE NO. BILL kTAT CYCLE STATUS DATE BMd CBM INd MONTHLY PAY AMT <br /> 9554 HAZMAT I 1 11 11 1 1 1 1 1 1 1 1 1 1 1 1. 3/15/12 <br /> LAST - RECIPIENT - FIRST MI TITLE CIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT CHARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2012 Hazmat Fee $360.008 1 P43009-01 <br /> 30 014290010 1 Hazmat Penalty Fee $36.00 8 1 04 00 .0 <br /> p8q I q429OOrO I Gen 5Q5 Tons Permit $1672.00 8 1 P43009.01 <br /> p8q 1 014290010 Permit Fee Penalty $1672.00 8 1 P43009.01 <br /> 80 O 2 00 0 State Surcharge Fee $24.00 8P43009.01 <br /> 80 1 014290010 Electronic Surcharge Fee $25.00 8q P43009.01 <br /> 80 1 002qOO-p p8q4 00 .0 <br /> TOTAL $3789.00 <br /> PRIOR STREET CITYZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CUSTOM METAL FINISHING 209-505-0037 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 1550 SHAW RD#C STOCKTON CA 95215 <br /> ST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> CUSTOM METAL FINISHING 209-505-0037 <br /> EMPLOYER STREET r'.1TY ST- 71P rnnF <br /> 1550 SHAW RD#C STOC�I�T0, CA 95215 <br /> (�{` ii.� CHECKED BY IDATE COL. 20 (3188) <br />